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      Clinical Audit of COPD Patients Requiring Hospital Admissions in Spain: AUDIPOC Study

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          Abstract

          Backgrounds

          AUDIPOC is a nationwide clinical audit that describes the characteristics, interventions and outcomes of patients admitted to Spanish hospitals because of an exacerbation of chronic obstructive pulmonary disease (ECOPD), assessing the compliance of these parameters with current international guidelines. The present study describes hospital resources, hospital factors related to case recruitment variability, patients’ characteristics, and adherence to guidelines.

          Methodology/Principal Findings

          An organisational database was completed by all participant hospitals recording resources and organisation. Over an 8-week period 11,564 consecutive ECOPD admissions to 129 Spanish hospitals covering 70% of the Spanish population were prospectively identified. At hospital discharge, 5,178 patients (45% of eligible) were finally included, and thus constituted the audited population. Audited patients were reassessed 90 days after admission for survival and readmission rates. A wide variability was observed in relation to most variables, hospital adherence to guidelines, and readmissions and death. Median inpatient mortality was 5% (across-hospital range 0–35%). Among discharged patients, 37% required readmission (0–62%) and 6.5% died (0–35%). The overall mortality rate was 11.6% (0–50%). Hospital size and complexity and aspects related to hospital COPD awareness were significantly associated with case recruitment. Clinical management most often complied with diagnosis and treatment recommendations but rarely (<50%) addressed guidance on healthy life-styles.

          Conclusions/Significance

          The AUDIPOC study highlights the large across-hospital variability in resources and organization of hospitals, patient characteristics, process of care, and outcomes. The study also identifies resources and organizational characteristics associated with the admission of COPD cases, as well as aspects of daily clinical care amenable to improvement.

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          Most cited references17

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          COPD exacerbations .1: Epidemiology.

          The epidemiology of exacerbations of chronic obstructive pulmonary disease (COPD) is reviewed with particular reference to the definition, frequency, time course, natural history and seasonality, and their relationship with decline in lung function, disease severity and mortality. The importance of distinguishing between recurrent and relapsed exacerbations is discussed.
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            Temporal clustering of exacerbations in chronic obstructive pulmonary disease.

            Exacerbations are important events in chronic obstructive pulmonary disease. Preventing exacerbations is a key treatment goal. Observational data suggest that after a first exacerbation, patients may be at increased risk of a second exacerbation, but this has not been specifically studied. We hypothesized that exacerbations may cluster together in time, a finding that would have important implications for targeting preventative interventions and the analysis of clinical trial data. To assess whether exacerbations are random events, or cluster in time. A total of 297 patients in the London chronic obstructive pulmonary disease cohort recorded daily symptoms and were assessed for a total of 904 patient-years. The observed timing of second exacerbations after an initial exacerbation was compared with that expected should exacerbations occur randomly. The observed timing distribution of second exacerbations differed significantly (P < 0.001) from the expected exponential function (shape parameter of the fitted Weibull function, 0.966 [95% confidence interval, 0.948-0.985]), suggesting that more second exacerbations occurred sooner than later and that exacerbations cluster together in time. Twenty-seven percent of first exacerbations were followed by a second recurrent event within 8 weeks. Approximately one third of exacerbations were recurrent exacerbations. Although initial exacerbations were milder than isolated events, they were not less likely to receive treatment, and under-treatment of initial events is not a plausible explanation for exacerbation recurrence. Recurrent exacerbations contribute significantly to overall exacerbation frequency (rho = 0.81; P < 0.0001). Exacerbations are not random events but cluster together in time such that there is a high-risk period for recurrent exacerbation in the 8-week period after an initial excerbation.
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              UK National COPD Audit 2003: Impact of hospital resources and organisation of care on patient outcome following admission for acute COPD exacerbation.

              Acute chronic obstructive pulmonary disease (COPD) exacerbations use many hospital bed days and have a high rate of mortality. Previous audits have shown wide variability in the length of stay and mortality between units not explained by patient factors. This study aimed to explore associations between resources and organisation of care and patient outcomes. 234 UK acute hospitals each prospectively identified 40 consecutive acute COPD admissions, documenting process of care and outcomes from a retrospective case note audit. Units also completed a resources and organisation of care proforma. Data for 7529 patients were received. Inpatient mortality was 7.4% and mortality at 90 days was 15.3%; the readmission rate was 31.4%. Mean length of stay for discharged patients was 8.7 days (median 6 days). Wide variation was observed in all outcomes between hospitals. Both inpatient mortality (odds ratio (OR) 0.67, CI 0.50 to 0.90) and 90 day mortality (OR 0.75, CI 0.60 to 0.94) were associated with a staff ratio of four or more respiratory consultants per 1000 hospital beds. The length of stay was reduced in units with more respiratory consultants, better organisation of care scores, an early discharge scheme, and local COPD management guidelines. Units with more respiratory consultants and better quality organised care have lower mortality and reduced length of hospital stay. This may reflect unit resource richness. Dissemination of good organisational practice and recruitment of more respiratory specialists offers the potential for improved outcomes for hospitalised COPD patients.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2012
                31 July 2012
                13 August 2012
                : 7
                : 7
                : e42156
                Affiliations
                [1 ]Instituto de Investigación, Hospital 12 de Octubre, Madrid Spain
                [2 ]Centre for Biomedical Research on Respiratory Diseases (CIBERES). Instituto de Salud Carlos III, Madrid, Spain
                [3 ]Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Seville, Spain
                [4 ]Hospital Universitario Marqués de Valdecilla, Santander, Spain
                [5 ]Complejo Hospitalario de Navarra, Pamplona, Spain
                [6 ]Hospital Nuestra Sra. de Sonsoles, Ávila, Spain
                [7 ]Complejo Hospitalario San Millán, Logroño, Spain
                [8 ]Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
                [9 ]Centre for Biomedical Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
                [10 ]Department of Statistics and Operational Research, Universidad de Castellón, Castellón, Spain
                [11 ]Hospital Universitario Morales Meseguer, Murcia, Spain
                [12 ]Hospital Virgen de la Salud, Toledo, Spain
                [13 ]Hospital Universitario Son Espases, Balearic Island, Spain
                [14 ]Instituto del Tórax, Hospital Clìnic, Barcelona, Spain
                Public Health Agency of Barcelona, Spain
                Author notes

                ¶ Membership of the AUDIPOC Study Group is provided in the Acknowledgments.

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: JLLX CJAM ACA AA. Analyzed the data: FPR JLLC CJAM ACA VA AF. Wrote the paper: FPR JLLC CJAM ACA AA. Principal investigator of the project: FPR. Members of the steering committee/scientific committee of this multicentre study: JLLC CJAM ACA AA. Regional research coordinators and local investigators of the project: RA JH JHH MB VA AF JMSN ELG BGC.

                Article
                PONE-D-12-09573
                10.1371/journal.pone.0042156
                3418048
                22911875
                19c703d3-9c5e-4f5a-a732-c7619a8ead6a
                Copyright @ 2012

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 31 March 2012
                : 2 July 2012
                Page count
                Pages: 12
                Funding
                This work was supported by Fondo de Investigación Sanitaria (FIS), Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación (PI 08/90129, PI 90486, PI08/90578, PI 07/90503, PI 08/90251, PI 07/90516, PI 08/90529, PI 07/90309, PI 08/90457, PI 08/90129, PI 07/90721, PI 08/90550, PI08/90447, PI07/90403, PI 08/90486), Spanish Respiratory Society (SEPAR) and CIBER de Enfermedades Respiratorias (CIBERES). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine
                Epidemiology
                Clinical Epidemiology
                Social Epidemiology
                Spatial Epidemiology
                Survey Methods
                Non-Clinical Medicine
                Health Care Policy
                Health Statistics
                Health Informatics
                Health Services Administration and Management
                Health Services Research
                Pulmonology
                Chronic Obstructive Pulmonary Diseases
                Smoking Related Disorders

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                Uncategorized

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